1. Field of the Invention
The invention relates to surgical devices; and, more particularly, to a device for performing emergency cricothyrotomies and tracheotomies.
2. Description of the Prior Art
Tracheostomy is an operation for the purpose of relieving an obstruction of the respiratory passage. One such prior art device is described in detail in U.S. Pat. No. 3,688,773 of which I am the inventor. In U.S. Pat. No. 3,817,250, of which I am co-inventor, an improvement of the device of my earlier patent is described. In general, both these prior art devices comprise an expandable needle, enlarged in a rear section and tapering to a sharp point for puncturing the skin and tissue of a patient. The sharp end of the needle is used to make the puncture and the entire needle is inserted into the trachea. An air tube is then inserted into the needle, expanding the same, and into the tracheal area to allow the patient to breathe.
In my copending application Ser. No. 701,916 filed Feb. 14, 1985 I described an improved apparatus and method for performing an emergency cricothyrotomy comprising a tracheostomy device which can be inserted into a patient's neck without danger of puncture of the posterior wall and which permits insertion of an airway tube without popping out of the device from the incision in the patient's neck or penetrating the posterior wall. An airway tube can be quickly and easily substituted for another airway tube of differing internal diameter without the need for redefining the puncture area or utilization of additional instrumentation. If desired, a closed system can be quickly and easily coupled to the device without the need for making a bigger opening in the patient's neck.
It is well known that young children have airways problems different from adults since their anatomy is not the same. These differences in anatomy create special problems when performing crictothyrotomies/tracheotomies on young children. Children have proportionally larger heads and tongues; they have epiglottis that protrude backward at an angle of forty-five degrees; larynxes that are more cephalad; cricoid cartilages that are narrower than the glottis; and vocal cords that are more susceptible to ulceration and trauma.
A newborn's glottis measures about 7 mm anterior-posterior and 4 mm transversely. This means that a mere 1 mm of mucosal edema reduces the glottal airway to 35 percent of its normal opening. The subglottic larynx of the infant is only 5 mm in diameter.
The cephalad position of the infant's larynx makes him or her an obligate nose-breather and creates wider angulation between the tongue and the larynx. The infant's cricothyroid is not easily palpable and is too small to be useful as an emergency airway.
The arytenoids are larger than an adult's in relation to the larynx. The epiglottis and other supraglottic structures have loosely attached mucous membranes with softer tissues and looser tissue planes, which facilitate more rapid development of edema and obstruction than do an adult's. The subglottic conus elasticus laryngis is also more prone than an adult's to develop edema. The entire larynx, including its cartilaginous skeleton, is softer and readily collapsible. The proximity of mediastinal structures to the larynx increases the risk of complications of tracheotomy, such as pneumothorax, mediastinal emphysema, and vascular erosion.
The infant has less respiratory reserve than the older child and the adult. The infant's resting oxygen consumption per unit of weight is twice that of the adult. Infants and young children have high peripheral airway resistance and greater tendency to airway obstruction because the diameter of the distal airway remains relatively small from birth to about 5 years of age. Finally, the infant has about twice the surface area per unit of weight as the adult, thus twice the heat loss.
Thus, it can be seen that many surgical instruments require a large space to operate in but a young child's anatomy only allows for a very small area in which to perform cricothyrotomies/tracheotomies. In such operations, it is necessary for the angle of penetration to be as close to 90 degrees to the anterior neck as possible. There is a need for an improved surgical instrument for performing such operations in young children. Resuscitative efforts in young children require the institutuion of quick, safe and adequate airways which can provide adequate suctioning. An instrument that is simple to insert, that protects against overpenetration, minimizes bleeding, causes minimal tissue damage and offers airways of different sizes is necessary. Surgical cricothyrotomy/tracheotomy is a dangerous and difficult method of airway management in a young child. Nasal and oral intubation for managing a blocked airway are not always successful. If one is unable to open the airway and ventilate the small child within 4 to 6 minutes, the results may be lethal. Causes for the surgical intervention may be due to inability to intubate in the presence of complete airway obstruction for any reason, such as foreign bodies that cannot be removed, trauma(penetrating, burns or blunt), swelling, epiglottitis and extubation difficulties.
Puncture of the cricothyroid membrane has been acknowledged as a preferred method of establishing an emergency airway in young children. The cricothyroid membrane, however, cannot always be found in young children under the ages of 12 to 14 and, therefore, penetration may be necessary at the inferior portion of the cricothyroid or into the first tracheal ring.
The trachea of the small child is softer and more readily collapsible. The proximity of the mediastinal structures to the area of tracheotomy increases the risk such as pneumothroax, mediastinal emphyseme and vascular complications. The trachea is more movable an tends to remain small in its diameter until 5 years of age. The cricothyroid membrane is near the C4 level in small children and moves to the C6 level by adulthood.
An ideal instrument for accomplishing an emergency cricothyrotomy/tracheotomy in the young child, ages 1 to 8, would have to be adaptable to perform the procedure in a small area. It would also have to be adaptable to patients of varying sizes, minimize tissue damage and bleeding, reduce the danger of overpenetration and assure simplicity of use. Such a device should establish airflow instantaneously and remain sterilized yet ready for immediate use.
In addition to the foregoing problems performing such operations, there is a need for improved surgical instruments for performing thoracostomies. In this operation, negative air pressure in the chest cavities creates special problems. In such operations, it is difficult to remove the trocar and chest tube. The flesh or walls of the puncture grasps the chest tube and makes it difficult to remove the holder for the tube so that the wound surrounding the tube can be sutured. There is thus a need for an improved surgical device for performing thoracostomies where the holder for the tube can be easily removed without the need for removing or disturbing the tube.
Thus, there is a need for an improved surgical instrument that is useful in both cricothyrotomies and thoracostomies where the holder for the respective tubes can be removed easily and quickly without the need for disturbing or removing the tube.